What to know about rotator cuff injuries

The rotator cuff is a group of muscles and tendons that converge at an area of the humerus (upper arm bone) called the greater tuberosity. 

The main function of the rotator cuff is to keep the shoulder joint stable while it moves. It does this by balancing the forces around the shoulder in all directions, which helps the joint move smoothly and stay in place.

Rotator cuff injuries are common, affecting nearly two million people every year in the United States. Aravind Athiviraham, MD, an orthopaedic surgeon at the University of Chicago Medicine who specializes in sports medicine, shoulder and knee surgery, answered some common questions about causes, treatment and recovery.

What is a rotator cuff injury?

Rotator cuff injuries are typically caused by one of three things: an acute injury or trauma, long-term overuse, or muscle and tendon tissue degeneration over time.

For older people, rotator cuff issues are simply a symptom of aging, which is why they’re most common in people over 60. (Younger patients are more likely to experience rotator cuff injuries through an acute injury or trauma, such as a fall or accident.)

The most serious rotator cuff injury is a full-thickness tear, which can be treated in various ways, depending on factors like how the injury happened, the size of the tear, number of tendons involved, the quality of the muscle, how long the injury has been present, the level of pain, how much it limits movement, and whether or not non-surgical treatments have failed. 

Athiviraham advises patients to seek a formal consultation with a physician, rather than self-diagnosis. 

“In the absence of significant trauma or instability event, it is less likely that someone under 40 is going to have a major tear,” he said.

It’s more likely, he said, that they are suffering from conditions that can be caused by overuse, such as tendonitis (inflammation or irritation of a tendon) or bursitis (inflammation of a bursa, a fluid-filled sac that cushions joints), or that they’ve torn the labrum (a type of tissue that lines the shoulder socket).

What are the most common ways people injure their rotator cuff?

For middle-aged patients, rotator cuff tears are most common in individuals like laborers who perform heavy physical work, or as a result of a traumatic incident such as a fall or a seizure, especially when that injury leads to a shoulder dislocation.

In people older than 60, it’s a mix between traumatic and atraumatic tears — and many people may not realize they have a small tear until something exacerbates it. 

“There are many patients who were doing fine, but for some reason — perhaps playing golf or tennis with an undiagnosed tear — the activity triggered a flare-up of symptoms," Athiviraham said.

"Alternatively, the symptoms could gradually worsen over time due to overuse.” 

The most common symptoms of rotator cuff tears are:

• Pain or weakness in the arm or shoulder with overhead activity
• Struggling to lift or reaching for objects
• Pain that disrupts sleep overnight or prevents a person from laying on one side
• Limited mobility in the arm

If you are worried you may have injured your rotator cuff, make an appointment with your primary care physician as soon as possible.

How are rotator cuff injuries treated?

How a rotator cuff injury is treated depends on a variety of factors, such as the duration of the injury, the patient’s age and activity level, and the severity of their pain and its impact on daily life.

Not all rotator cuff injuries require surgical intervention, particularly if the injury or tear is chronic and was caused by slow deterioration over time. In these cases, patients may consider nonsurgical interventions, such as cortisone injections or physical therapy, before moving toward operative interventions, if needed.

Because chronic tears happen over time, bodies often adapt to them. Physical therapy may be enough to get a patient back to baseline mobility without having to resort to surgery. 

In these chronic cases where there has simply been a flare of pain, it would be like “managing any other overuse injury — therapy and anti-inflammatories can help, and in the right setting, injections may also be viable options,” Athiviraham said.

However, when a patient presents with an sudden onset traumatic tear, surgery may be recommended, as these patients often experience more severe pain and disability. In such cases, the tissue quality is typically better, and if the repair is done promptly, it can lead to a more successful recovery.

Still, “it’s a nuanced discussion,” Athiviraham said. “The decision could go any number of different ways based on a patient’s preference and their activity levels.”

How long does it take to recover from rotator cuff surgery?

Expected recovery timeline from rotator cuff injuries can vary widely, but for some patients it can take as long as six months to one year, especially in older patients with less healthy tissue.

Unlike with joint replacements, where patients are typically encouraged to get up and moving as quickly as possible, recovering from rotator cuff repair requires a more cautious approach.

Because the surgery repairs torn tendons that need to heal to bone, those tissues need time to heal. So, while physical therapy is key to recovery, a patient’s first focus should be to rest and protect the repair.

“You have to be a little more cautious early on, because you don't want it to re-tear,” Athiviraham said. “If it was a small to mid-sized tear, I would advise them to start at maybe three to four weeks. If it's a mid- to large-sized tear, then I would wait four to six weeks to begin therapy.” 

Patients typically go home the same day after having rotator cuff surgery, but they’ll likely be in an arm sling for up to six weeks. If the surgery was done on their dominant arm, they may need assistance with driving until the sling can be safely removed.

Athiviraham also advises patients that they may feel more comfortable sleeping upright for the first couple of weeks, so part of the surgery pre-planning may involve renting or buying a reclining chair that is comfortable enough to sleep upright in.

How you can prevent rotator cuff injuries?

For younger people, overall core upper body strength is important for prevention.

“You have several muscles around your shoulders called scapular stabilizers — essentially, your shoulder blade muscles — that are often forgotten about,” Athiviraham said. “Keeping those muscles strong can help support the overall biomechanics of the shoulder, so that you're not overusing your rotator cuff or causing tendonitis, which is one of the most common causes for shoulder problems in people under 60.” 

Competitive athletes or people with highly physical jobs should pay particular attention to when and how they’re using their bodies. Varying your exercise routine is also important to maintain balance and avoid that overusing any one joint.

For older patients, avoiding injuries and falls is key to reducing the risk of rotator cuff tears and other injuries.